Routine preoperative testing before low-risk surgery is widely viewed as having low value.
A new research article indicates that routine preoperative testing before low-risk surgery is common despite having low value.
Over the past decade, healthcare reformers have called on the industry to reduce unnecessary tests. For example, the Choosing Wisely campaign was launched in 2012 to spur conversations between clinicians and patients about care that is truly necessary.
The new research article, which was published by JAMA Internal Medicine, is based on an analysis of administrative claims data in Michigan from January 2015 to June 2019. The researchers examined routine preoperative testing for three low-risk ambulatory surgeries: lumpectomy, gall bladder removal, and groin hernia repair. The surgeries were conducted on 40,000 patients.
51.6% of the patients underwent one or more preoperative tests, 29.4% of patients had two or more tests, and 13.5% of patients had three or more tests
The most common tests were complete blood cell count (33.1%), electrocardiograms (25.2%), and basic metabolic panel (11.3%)
Older patients and patients with comorbidities were more likely to undergo preoperative testing
"In this study of patients undergoing three common low-risk surgical procedures, preoperative testing was common, with approximately 52% of patients undergoing at least one test and 29% undergoing two or more tests," the research article's co-authors wrote.
Interpreting the research
This kind of testing clearly generates little value, Lesly Dossett, MD, division chief of surgical oncology at Michigan Medicine and the co-director of MPrOVE said in a prepared statement. "There aren't that many areas in medicine where the data is pretty definitive that something is low-value, but preoperative testing before low-risk surgeries is certainly one of them."
For most patients, preoperative testing before low-risk surgery should be a relic of the past, she said. "There was probably a time when some of the testing did reduce adverse events. But now there's been so many advances in surgery—complication rates are so low—that a lot of these tests are not necessarily helpful anymore."
Older patients and patients with comorbidities may require preoperative testing for low-risk surgery, but even those circumstances can result in unnecessary testing, said Nicholas Berlin, MD, MPH, a Michigan Medicine plastic surgery resident and lead author of the research article. "That's not to suggest there's an age threshold or a comorbidity that requires preoperative testing every single time. There's not."
Conducting preoperative tests generates revenue for hospitals, so there is an economic incentive for low-value preoperative tests to continue. But the country cannot afford the status quo, said Hari Nathan, MD, PhD, division chief of hepato-pancreato-biliary surgery at Michigan Medicine and director of the Michigan Value Cooperative.
"At the end of the day, we all recognize that as a society, we need to find ways to curb healthcare costs. That's in everybody's interest. Even if, on your balance sheet, you think it makes sense to do more tests just to make money, as healthcare providers and as a nation, it does not make sense. It is unsustainable."
Allina Health and Aetna still negotiate reimbursement for the health system's services but they bargain as amicable partners.
The Allina Health | Aetna health plan joint venture is capitalizing on its parent organizations' resources and a collaborative spirit, a pair of top executives say.
There are three primary types of "payvider" healthcare organizations. A healthcare provider can establish its own health plan. A healthcare payer can establish its own provider division. And a healthcare provider and payer can come together in a joint venture.
The Allina Health | Aetna joint venture was announced in January 2017, and it began offering fully insured and self-insured products in early 2018. Aetna is a division of Woonsocket, Rhode Island—based CVS Health. The joint venture has forged a collaborative relationship between Minneapolis-based Allina Health and Aetna, says Richard Magnuson, MBA, chief financial officer of Allina.
"We work in ways that align incentives that are more collective and in ways with more shared-risk models, so that you are jointly working together to ensure that what is best for the patient is best for both Allina and Aetna. It takes leadership from all sides to come at this with a different mindset," he says.
The joint venture has succeeded in stepping away from the traditionally contentious relationships between providers and payers, Magnuson says.
"Where the industry has been in the past—and it is not going to work in the future—is my job as the provider is to get as much from the payer as possible and get rewarded every time I do something with a member. In the past, the health plans have tried to reduce what they pay the provider and to put administrative hurdles in place for the provider to get paid. What that does is create a lot of administrative non-value-added work," he says.
In the joint venture, there is still negotiation over reimbursement for Allina's services, but the negotiation does not happen from a point of conflict, says Tom Lindquist, MBA, CEO of Allina Health | Aetna, which is based in St. Louis Park, Minnesota.
"The negotiation happens in the context of what is going on in the environment—what is happening with medical cost trends, what is happening with the overall health cost environment, and what we need to do to make the negotiation a win-win situation while holding costs as low as possible for the individuals we serve. That is the primary difference—no one side of the negotiation is trying to one-up the other. It is about finding the best landing spot so we can go about the business of the business, which is improving health outcomes, medical care, and patient experience," Lindquist says.
Sharing resources
The joint venture has been an effective vehicle for sharing resources between Allina and Aetna, Magnuson says.
"We have some collaborative clinical teams that work on opportunities to meet the care needs of our patient population. So, we bring together our clinical folks and their clinical folks on a periodic basis to help address those needs. From a data perspective, we can bring together data from the care side and the payer side in a way that helps us understand the patient as a person. If we were just a payer or provider, we could not do that. Lastly, we bring together a small group of our administrative teams to help work through issues from each of the owners' perspectives," he says.
The administrative teams meet regularly, Magnuson says. "About every six weeks, a couple of my Allina colleagues and I, some of the Aetna folks, and some of the joint venture folks come together on issues such as product design. We come together to create product design that meets the consumer's needs, Allina's needs, and Aetna's needs."
Allina and Aetna have shared resources in a recent Medicare initiative, Lindquist says. "In our Medicare program, we developed a complex-care-for-seniors initiative. We worked with both the Aetna infrastructure and the Allina clinical team to develop the program. It is going to utilize extra resources and clinical care from Allina along with the educational resources and outreach technology from Aetna to help improve results for the most vulnerable within the Medicare population. That initiative kicked off in January of this year."
Keys to joint venture success
Lindquist and Magnuson say there are several factors involved in achieving joint venture payvider success.
There must be willingness among the provider, payer, and joint venture organizations to have open, honest, and frank discussions about the business, where it is going, and what they want to accomplish. "Just like any joint venture, you need to keep the dialogue going," Magnuson says.
The payer, provider, and joint venture organizations must make sure that their goals are aligned.
There needs to be flexibility. "With the coronavirus pandemic, the changes have been incredible. So, the ability to be flexible is critical," Lindquist says.
You need to think about the joint venture in unique and different ways—not just coming at the joint venture from a payer lens or a provider lens.
You need to come together and collectively come up with more affordable and effective care in a way that you probably cannot do on your own.
You need to be open to seeing things from the other organization's perspective.
The payer and provider organizations need to listen and learn from each other.
The joint venture needs to be able to align around patients in a way where traditional incentives have not worked in the fee-for-service world. "You need to come together in a way that is best for the patient," Magnuson says.
Measuring joint venture performance
The Allina Health | Aetna joint venture has focused on several metrics to measure success, Magnuson says.
"Similar to most health plans, a key metric in the joint venture is about membership and how many members you are providing care for. From Allina's perspective, we watch how many members are attributed—how many members are getting their care from Allina. So, the joint venture wants to see growth overall and as much care as possible being provided by Allina. Patient satisfaction and engagement are also critical," he says.
The effort to build and open Wexford Hospital has included several obstacles, including keeping construction workers safe.
Allegheny Health Network has had to rise to several challenges in opening a new hospital during the coronavirus pandemic.
Constructing and opening a new hospital is a daunting task under the best of circumstances. The effort is more arduous during a global pandemic, with logistical and operational barriers to overcome.
AHN is set to open Wexford Hospital in Wexford, Pennsylvania, in September. The hospital is being built next to AHN's Wexford Health + Wellness Pavilion, a large outpatient services facility. Features of the 160-bed hospital include a women's labor and delivery unit, neonatal intensive care unit, a 24-bed emergency department, and a variable acuity ICU.
One challenge has been keeping construction workers safe, says Wexford Hospital President Allan Klapper, MD.
"Education was critical. We kept our construction colleagues informed of what they needed to do to stay safe—what symptoms to be concerned about, how to stay socially distanced, wearing masks, and adding personal protective equipment stations into the facility. They had daily safety meetings. We were fortunate that when COVID hit, most of the work was being done outside, and the building had not been completely enclosed," he says.
AHN has also made pandemic-related medical services available to construction workers, Klapper says. "We reached out to our construction colleagues when it came time for the coronavirus testing and vaccination programs that we were doing to make sure that those programs were available to them."
The hospital project's construction contractor, Providence, Rhode Island-based Gilbane, had to closely monitor the ordering of materials, he says. "When COVID first hit and work stopped across the world, Gilbane and the trades had to go through and determine which materials had yet to arrive and where they were coming from. If the materials were coming from overseas or there was the potential for delays, they ordered those materials as quickly as possible so we could get the materials on time and not have construction delays."
Staff recruitment
The pandemic has affected how AHN has recruited staff for Wexford Hospital, Klapper says.
"The biggest challenge has been that we had a schedule of events that were supposed to take place over the course of the past year to attract workers and inform the community about job opportunities that are available in the hospital. We could not do those in-person events during the pandemic, so we had to adapt a completely virtual recruitment program," he says.
The virtual recruitment effort has gone well, says Amy Cashdollar, DBA, RN, chief operating officer of Wexford Hospital. "I have been working with the talent team to do several virtual career fairs with the colleges in the area. One of the virtual career fairs attracted more than 120 people to hear about the job opportunities at Wexford Hospital. It was great to see that level of interest."
Staff training and orientation
AHN has adopted new approaches to staff training and orientation to open Wexford Hospital, Cashdollar says.
"From a training perspective, we are looking at a lot of different ways to deploy training. We are being mindful of group size and how large of a group we will be allowed to congregate. We are looking at hybrid education models, time in the building, time in the classroom, and training by Zoom. We plan to use a variety of different training methodologies to get employees set up from an orientation perspective," she says.
Community events
The pandemic has had a major impact on the ability of AHN to hold community events associated with the new hospital, Klapper says.
"At this point, we are at a standstill. We are planning two parallel pathways as we get closer to opening the hospital. First, under the assumption that enough of the population will be vaccinated and we do not have additional COVID surges, we will be able to have a ribbon-cutting and VIP ceremony. Although this kind of event may not be as large as what we would typically hold, it should be large enough with members of the community and our employees to celebrate the opening of the hospital. Second, we are being realistic that there could be another surge, and we could pivot to have a virtual event or an event on a much smaller scale," he says.
Researchers compared the estimation of the presence of disease by primary care clinicians and an expert panel.
Primary care clinicians overestimate the probability of disease before and after diagnostic testing, which likely leads to overutilization of treatment that could harm patients, a recent research article says.
With 14 billion laboratory tests performed annually in the United States, effective ordering and interpretation of tests is essential to avoid waste and overutilization of treatment such as medications and procedures. Diagnostic errors account for a significant proportion of serious harm to patients.
The recent research article, which was published by JAMA Internal Medicine, is based on data collected from more than 550 primary care clinicians. The clinicians were asked to estimate the probability of the presence of disease in clinical scenarios before and after diagnostic tests for four conditions. The probability estimates were compared to the estimates of an expert panel that determined the probability of disease based on a literature review that included diagnosis text books.
The researchers found that the primary care clinicians overestimated the probability of disease for all clinical scenarios before testing:
For pneumonia, the median estimate of pretest probability of disease by the primary care clinicians was 80%, compared to a range from 25% to 42% for the expert panel
For breast cancer, the estimate of pretest probability by the primary care clinicians was 5%, compared to a range from 0.2% to 0.3% for the expert panel
For cardiac ischemia, the estimate of pretest probability by the primary care clinicians was 10%, compared to a range from 1.0% to 4.4% for the expert panel
For urinary tract infection, the estimate of pretest probability by the primary care clinicians was 20%, compared to a range from 0% to 1% for the expert panel
The researchers found that the primary care clinicians also overestimated the probability of disease after positive test results:
For pneumonia, the estimated probability of the presence of disease by the primary care clinicians after positive radiology results was 95%, compared to a range from 46% to 65% for the expert panel
For breast cancer, the estimated probability of the presence of disease by the primary care clinicians after positive mammography results was 50%, compared to a range from 3% to 9% for the expert panel
For cardiac ischemia, the estimated probability of the presence of disease by the primary care clinicians after positive stress test results was 70%, compared to a range from 2% to 11% for the expert panel
For urinary tract infection, the estimated probability of the presence of disease by the primary care clinicians after positive urine culture results was 80%, compared to a range from 0% to 8.3% for the expert panel
"This survey study suggests that for common diseases and tests, practitioners overestimate the probability of disease before and after testing. Pretest probability was overestimated in all scenarios, whereas adjustment in probability after a positive or negative result varied by test. Widespread overestimates of the probability of disease likely contribute to overdiagnosis and overuse," the researchers wrote.
Interpreting disease overestimation
Overestimation of the probability of disease can have negative consequences, the lead author of the research article told HealthLeaders.
"If doctors overestimate chance of disease, they will often diagnose patients with diseases they do not have. There is no final test that is 100% accurate. Probability is central to making a diagnosis, and we need to consider probability both before and after testing, knowing that there are often overestimates that can lead to harms for patients. Overdiagnosis of disease leads to unnecessary and sometimes harmful treatments and procedures," said Daniel Morgan, MD, MS, professor of epidemiology, public health, and medicine at University of Maryland School of Medicine.
Most doctors likely overestimate the probability of disease, not just primary care providers, he said. "Humans are not naturally good at probability and medicine is extra difficult as we often do not get feedback. We often do not follow patients for long and many diagnoses are uncertain. Doctors like other people have biases such as neglecting how rare a disease is in a population—they remember recent or rare cases, and we are generally rewarded for making diagnoses even if they are incorrect."
Probability is often not applied effectively by clinicians, Morgan said. "Probability is the scientific basis for how we teach evidence-based diagnosis and how we conduct and interpret trials for the benefits of treatments. So, probability is central to diagnosis and treatment. However, medical practice often ignores this. A shaky understanding of probability likely leads to significant medical overuse."
Karmanos Cancer Institute CMO George Yoo is bullish on the future of telehealth in oncology care.
Telehealth is well-suited to providing a range of services for oncology patients, the chief medical officer of the Karmanos Cancer Institute says.
Telehealth has expanded exponentially during the coronavirus pandemic. However, in the long term, there is uncertainty about the future of telehealth, including whether government and commercial payers will continue to reimburse telehealth visits at rates comparable to in-person visits and which specialties will remain committed to utilizing telehealth.
Karmanos, which is part of Grand Blanc, Michigan–based McLaren Health Care, has 15 locations across Michigan. Karmanos CMO George Yoo, MD, is bullish on the future of telehealth in oncology care.
"Telehealth has become a great tool for many patients. Not everybody likes telehealth; but there are quite a few patients who like to use telehealth, especially patients who are frail and cannot travel or just live very far away from our main facility. Telehealth is a great tool, and it is going to stay in the future—it is not just going to be useful during the pandemic. Telehealth is a great way to give initial consults, for example," he says.
Convenience is a powerful driver for adoption of telehealth in oncology, Yoo says. "Telehealth is going to be a way for more and more patients to get oncology care from our institute. There are patients who do not want to travel three or four hours to our main facility in Detroit to see whether they really need a certain type of surgery, radiation, bone marrow transplant, or clinical trial. With telehealth, it is going to be much easier for patients to explore these services."
Telehealth is an excellent way to engage families when an oncology patient is facing advanced stages of cancer or end-of-life situations, he says. "When we have end-of-life discussions that are very sensitive, family input is tremendously important. With telehealth, the whole family can be present. It can be difficult to involve the family if the patient is coming into an office, clinic, or exam room, and they have to call their family members. With telehealth, family members can be present for the whole discussion."
As long as the possibility of coronavirus infection remains a concern, telehealth will remain an attractive care option for oncology patients, Yoo says.
"These patients are going through therapies that make them more immune-compromised than many other patients. The cancer itself can make patients immune-compromised. So, these patients are at risk if they get COVID—they get much sicker than other patients. Some patients are being very cautious and do not want to go out into a public environment where they could expose themselves to the coronavirus. So, they are finding it much more comfortable to stay in their home setting with telehealth."
About 90% of Karmanos' telehealth visits are conducted using video, says Scott McCarter, vice president of information technology. "There are some technology challenges that patients have—they may not have a cellphone that works like a smartphone. We have a very challenged population here in Detroit, where patients often do not have as much technology as other patients. It would be impossible to go to 100% video."
Oncology services fit for telehealth
There are several kinds of oncology patients and oncology services that are appropriate for telehealth, Yoo says.
1. Newly diagnosed patients: "For the new patient, telehealth is an excellent tool for a second opinion. It is an excellent tool for specialized care. Karmanos and McLaren Health Care have a network of cancer centers across the state. There is a lot of general treatment that can be done in these network sites. Telehealth visits can determine whether a patient has to come down to the main hospital in Detroit or not," he says.
2. Return patients: "For return patients, telehealth is a good tool when the care is mainly looking at results of tests; for example, a prostate cancer patient with a prostate-specific antigen test. If a patient is coming in for a yearly radiological test and they need to review the results, telehealth is an excellent tool," Yoo says.
3. Surgery consults: "Just about every type of surgical consult is appropriate for a telehealth visit. Some patients just want to get confirmation on whether a surgery can be performed. For example, I had a patient in Northern Michigan who wanted the surgery in Detroit, but she did not want to come down to the city twice. She did not want to come down just for a surgery consultation, then have to come down for the surgery," he says.
4. Radiation consults: "Telehealth is a good tool if the patient wants specialized radiation treatment. For example, we have a gamma knife, which is specialized delivery of radiation to the brain. Telehealth consultations are good for determining whether gamma knife or standard radiation is more appropriate. Any time when there are specialized services, it can be appropriate to have a telehealth visit for consultation. The patient does not want to travel just to be told that they are or are not a candidate for a specialized service," Yoo says.
5. Genetic consultations: "Right now, about 80% of our genetic consultations are being conducted via telehealth. A lot of information can be exchanged between the patient and the genetic counselor through questions. An exam is not necessarily important; and if any testing is ordered, the results can be followed up with the patient. There are certain specialties such as genetic counseling and palliative care that lend very well to telehealth," he says.
6. Psychological and palliative counseling: "Those services are provided through telehealth visits. It is up to the preference of the patient. A lot of patients still want to have face-to-face contact for palliative care and psychological care. But telehealth tends to work very well for those specialties because clinicians do not have to make physical contact in the evaluation of a patient. A lot of the care can be done verbally and by video," Yoo says.
Burnout mitigation includes streamlining communication and vocalizing appreciation, chief medical officer says.
It is imperative for healthcare organizations to address physician burnout, the chief medical officer of a Dallas-based clinically integrated network says.
Burnout is one of the top challenges facing physician and other healthcare workers nationwide. A report published in September by The Physicians Foundation found that the coronavirus pandemic has worsened physician burnout. Research published in September 2018 indicated that nearly half of physicians across the country were experiencing burnout symptoms.
"Burnout is real. If we do not address the causes of burnout, we are going to lose good providers, and we cannot afford that as a country," says Jason Fish, MD, senior vice president and CMO of Southwestern Health Resources in Dallas. The clinically integrated network features nearly 5,000 physicians and advanced practice providers.
Fish says four actions can ease physician burnout.
1. Streamlining communications
Reducing unnecessary emails and noncritical data can help reduce physician burnout, he says.
"For email and communication in general, as providers we are being completely overwhelmed from so many different angles. Everybody wants a piece of the physician. So, what we have tried to do is to streamline our communication. If we are not asking what is valuable to the providers, then we are missing the mark," Fish says.
Physicians should not be overloaded with email, he says. "For us, when we communicate, we do not want 20 different people communicating with our providers. We want to streamline our email. We try to step back and see how we can combine those communications or find communications that we can let go of if there is no value in them. Or we try to direct communications to somebody else because those communications may not be of value to the provider—they may be of value to the office manager."
Similarly, physicians should be presented with critical data, he says.
For example, Southwestern Health Resources has used predictive analytics to harness data related to their efforts for coronavirus vaccination. "Here in Texas, when coronavirus vaccines became available, the first people who were eligible for vaccine were everyone who was 65 years old or older. But there were groups within that age cohort who were at higher risk than others. So, we were able to run our patients through a predictive algorithm based on where they lived, social determinants, medical conditions, and past utilization patterns to prioritize who should get the vaccine," Fish says.
Focusing on high-risk patients has allowed Southwestern Health Resources physicians to manage vaccination data, he says. "If primary care provider had a panel of 2,500 adult patients, with 1,800 patients over age 65, it is not helpful to send the provider a list of all 1,800 patients. Instead, we sent a tiered list of patients. So, if there were 200 patients at highest risk, we told the provider to get them in for vaccination. The provider could get on the phone and answer questions about the vaccine and tell patients where they could get vaccinated. All 1,800 of the older patients are important, but we wanted to guide providers with a hierarchy."
2. Vocalizing appreciation
Acknowledging good performance can be a powerful tool to reduce burnout, Fish says. Southwestern Health Resources recognizes top performers during regular "pod meetings," which are organized by large physician practices or combinations of smaller practices, he says. "For example, we had a practice during the early phase of the pandemic that was the first out of the gate doing testing in the parking lot. It was new. We showcased that—we highlighted that. We celebrated that in our network through our pod meetings, through our newsletters, and through our website."
Vocalizing appreciation promotes the sharing of best practices and effective initiatives, Fish says. "When you have teams that are doing great work, rather than just giving out accolades, you want them to share their stories. You want to share how they did great work with other practices. That is another way you can celebrate the good work. You want to permeate that good work across the organization."
3. Implementing team-based models of care
Promoting teamwork is another way to combat physician burnout, he says. "One thing we have done is to help engineer team-based models of care in the clinics. We have a performance improvement team that goes into the clinics and helps them build team-based models of care. The PI team can help clinics design daily huddles and move clinics to team-based models of care within their staff."
Team-based models of care help physicians manage medically complex patients, Fish says. "You bring in all of the adjunct staff—the care management team, the utilization team, the disease management team, and the quality team for the coders for clinical documentation. You wrap these individuals around the providers to form a team, which brings value to the providers, then the providers do not feel like they are on a journey with complex patients alone."
Including care managers and social workers in a physician practice team can also reduce burnout, he says. "When you add a care manager and a social worker to the team, you can find out what is going on in the home or what is going on in the neighborhood. You can find out barriers that patients have to living their optimal health and to have their best quality of life. You can connect patients to community resources. That kind of team is incredibly important to driving success and taking burdens off providers."
4. Working at top of medical license
To limit burnout, healthcare organizations should ensure that physicians are working at the top of their medical license, Fish says.
"If you want providers to Google community resources for their patients or sift through a list of 2,000 patients to figure out which ones are at risk, you are going to have physician burnout. You need to use the analytics platform, and you need to use the team that you have such as social workers and care managers. The physician's job should be working with the patient around counseling for optimal health, diagnosing critical disease, and managing critical disease. The minute you pull a physician into other things, they are not working at the top of their license."
In 2020, less than half of doctors worked in a practice wholly owned by physicians for the first time, according to American Medical Association data.
The historical shifts toward larger physician practices and away from physician owned practices accelerated between 2018 and 2020, according to a new American Medical Association data report.
Once a mainstay of the U.S. healthcare system, small physician practices are dwindling in number. In addition, the number of physician practices owned by hospitals or health systems is on the rise.
The new AMA data report is based on information collected in the organization's Physician Practice Benchmark Surveys. The surveys are nationally representative and collect data from post-residency physicians who provide at least 20 hours of patient care weekly. The surveys have been conducted every other year since 2012.
The new report includes several key data points:
In 2020, 49.1% of physicians worked in a private practice, marking the first year that less than half of doctors worked in a practice wholly owned by physicians. In 2018, 54.0% of physicians worked in a private practice. In 2012, 60.1% of physicians worked in a private practice.
There has been an ongoing shift from physicians owning practices to physicians working as employees. In 2020, 50.2% of physicians were employees. In 2018, 47.4% of physicians were employees. In 2012, 41.8% of physicians were employees.
Gender and age are correlated with the likelihood for a physician to be employed, with female doctors and younger doctors more likely to be employed than male doctors and older doctors. In 2020, 56.5% of female doctors were employed compared to 46.7% of male doctors. In 2020, 70.0% of doctors under age 40 were employed compared to 42.2% of doctors who were 55 and older.
The percentage of physicians working in small practices has fallen steadily. In 2020, 53.7% of physicians worked in practices with 10 or fewer doctors. In 2018, 56.5% of physicians worked in practices with 10 or fewer doctors. In 2012, 61.4% of physicians worked in practices with 10 or fewer doctors.
The percentage of physicians working in large practices has been rising. In 2012, 12.2% of physicians worked in practices with at least 50 doctors, with the numbers increasing to 14.7% in 2018 and 17.2% in 2020.
Interpreting the data
Physicians appear to be shifting from private practice to working at hospitals and health systems, the AMA data report says. "As the number of physicians in private practice has fallen, the share of physicians who work directly for a hospital or for a practice at least partially owned by a hospital or health system has increased, changing from 29.0% in 2012 to 39.8% in 2020."
There is an established trend of fewer physicians owning practices and more physicians working as employees, the report says. "The changes between 2012 and 2020 reflect the continuation of a longer-term shift from physicians as practice owners to physicians as employees of practices or of other organizations."
There are several possible ways that physicians have shifted to larger practices and practices owned by hospitals or health systems, the report says. "These include mergers and acquisitions among practices (or acquisition of a practice by a system), practice closures, physician job changes, and new physicians entering practice in settings different than those from which retiring physicians are leaving."
Horizon Blue Cross Blue Shield of New Jersey is targeting members with high social determinants of health needs.
Horizon Blue Cross Blue Shield of New Jersey is operating an ambitious social determinants of health (SDOH) program for targeted members in partnership with several healthcare provider organizations.
Social determinants of health such as food security and transportation are believed to have much more impact on a person's health status than clinical care. Healthcare providers have pursued two primary strategies to address SDOH: direct investment in social determinant programs or SDOH partnerships.
In April 2017, Horizon launched a pilot SDOH program in partnership with West Orange, New Jersey-based RWJBarnabas Health. The pilot program targeted about 1,000 Horizon members in four Newark zip codes. "They were high-cost members who were identified through predictive modeling. We built a community health worker model. Then we measured the impact after two years, both on cost of care and the health status of the members," says Allen Karp, MBA, executive vice president of healthcare management and transformation at Horizon.
The pilot program achieved a 25% reduction in total cost of care. "Those members were utilizing emergency rooms, they were being admitted to hospitals, they were being readmitted, and they were running up significant costs. They were not well-connected to the healthcare system—nobody was coordinating care for them," he says.
In April 2020, Horizon launched an expanded version of the pilot program called Horizon Neighbors in Health. The program includes 10 partners. Eight of the partners are healthcare provider organizations, including four of New Jersey's largest health systems—Atlantic Health System, Hackensack Meridian Health, RWJBarnabas Health, and St. Joseph's Health. The two other partners are Penn Medicine for community health worker training and NowPow, which features an online platform that can connect people with community-based resources.
How Horizon Neighbors in Health works
The Horizon Neighbors in Health program has five essential components, says Valerie Harr, director of community health for Horizon.
1. Community health workers: About 40 community health workers have been hired to work in the Horizon Neighbors in Health program. Horizon's healthcare provider organization partners recruit and hire the community health workers and Horizon pays for half of the salary cost.
"Community health workers are recruited from the local community. If we are working with St. Joseph's, the community health workers live in Passaic and Patterson. Resumes and degrees are not as important as being a trusted member of the community. Candidates need to understand the needs of the community and have the ability to connect with individuals," Harr says.
The community health workers are advocates for the members who are served by the Horizon Neighbors in Health program, she says. "People are often reluctant to ask for help. But if someone approaches them who is a neighbor, who speaks their language, and who looks like them, then they may open up. The community health worker is responsible to help identify the goals of the member and to make community connections."
The original plan for the community health workers was for them to have face-to-face interactions with members, but the coronavirus pandemic necessitated shifting to telephonic contact with members.
2. Screening: Community health workers screen targeted Horizon members for nearly two dozen SDOH. "These community health workers have conversations with our members—they build a rapport with members while going through the screening tool," Harr says.
3. Geographic approach: Horizon has used U.S. Census data to target members in communities with high SDOH needs, she says. "Horizon's footprint is nearly statewide, but Horizon Neighbors in Health is not yet in every county. We are in 15 counties and more than 120 zip codes. That is intentional. We are targeting the communities with the members who have the most need."
4. Personal health assistants: Horizon has hired and fully funded four personal health assistants to support the community health workers, Harr says. "They each have a provider partner that they are responsible for, and they have daily huddles with their respective partners to troubleshoot issues that community health workers are encountering. The personal health assistants can connect members with resources such as care management or our behavioral health team. They also troubleshoot issues around pharmacy."
5. Data analytics: "Working with McKinsey & Company consultants, our analytics team has built multiple predictive algorithms using claims data, consumer purchasing data, Census data, and other SDOH data to zero in on the members who can benefit most from having a community health worker engage with them," she says.
Emphasis on community resources
The primary goal of the Horizon Neighbors in Health program is to connect members with SDOH needs to community-based resources, Harr says.
"NowPow is known for having connections to community resources. In New Jersey, they have more than 20,000 community organizations loaded into their platform. When a community health worker engages with a member and identifies needs through the screening process, NowPow identifies the potential community resources for that member. For example, if a member has food insecurity, NowPow can identify a food pantry in that person's neighborhood," she says.
In some cases, Horizon pays to meet a member's SDOH needs, Harr says. "We do have funding set aside as part of the Horizon Neighbors in Health program to be able to pay for short-term assistance that may not be available through a community resource. For example, we had a member living on the second floor of a home with a broken chair lift. She had been crawling up and down her stairs. So, we paid for the installation of a new chair lift."
Metrics and mission
Horizon expects to have data that measures the impact of Horizon Neighbors in Health next month. The data will include several metrics, Harr says.
Process metrics such as how many members are reached, needs that are identified, and referrals
Excess spend, which is defined as avoidable emergency room visits and inpatient admissions
Total cost of care
Qualitative metrics related to chronic conditions
Pharmacy utilization
"Ultimately, for us to see whether we are having an ROI, we must engage a large enough pool of members and reduce excess spend. That will get us the ROI," she says.
A recently published progress report on the Horizon Neighbors in Health program includes three key data points through December 2020.
More than 2,500 Horizon members were enrolled in the program
The Top 3 needs identified were financial stability, access to basic healthcare, and food insecurity
The Top 3 referrals were food pantries, utility payment assistance, and rent and mortgage assistance
Horizon is dedicated to addressing SDOH, Karp says.
"We are committed to solving disparities in healthcare and underserved communities in New Jersey. We cover not only commercial members but also more than a million Medicaid members and a significant share of the individual insured market. We want to ensure that our members have appropriate access to care, so they can achieve their best health. Many members face a lot of barriers to care because of where they live such as lack of transportation and housing," he says.
The health system is expanding its virtual care services from the acute care setting to urgent care.
Dartmouth-Hitchcock Health (D-HH) has partnered with MDLIVE to offer virtual urgent care visits.
The virtual urgent care market is well established, with MDLIVE and several competitors in the space such as Teledoc, Doctor On Demand, and Amwell. Urgent care and behavioral health are two of the most common telemedicine services.
Launching D-HH Virtual Urgent Care is a logical and strategic step for the Lebanon, New Hampshire-based health system, says Mary Lowry, MBA, administrative director of Dartmouth-Hitchcock Connected Care. "At Dartmouth-Hitchcock, we started growing our telemedicine portfolio of services in the acute care space. We have launched virtual urgent care to round out our telemedicine portfolio."
D-HH Virtual Urgent Care, which launched on March 15, utilizes the MDLIVE telemedicine platform and offers visits via video or telephone. The service provides treatment for dozens of common conditions, including upper respiratory illnesses, allergies, rashes, bug bites, gastrointestinal maladies, and urinary tract infections. The service, which is offered 24/7 year-round including weekends and holidays, is available to anyone in any state or U.S. territory.
D-HH and MDLIVE physicians are staffing the service, says James B. Ebert Jr., MD, medical director of D-HH Virtual Urgent Care. "We have a core team of 14 Dartmouth-Hitchcock emergency medicine physicians who are all board certified and have a long history of telehealth experience. That core team provides the bulk of the service, but we also have our MDLIVE partnership that provides additional physician coverage when it is needed."
The physicians can prescribe medications and send prescriptions to a pharmacy of a patient's choice.
D-HH Virtual Urgent Care is designed to be convenient for patients, Lowry says. "There are a couple of different options. The patient can say that they want to see the next available provider, or they can schedule their visit for later in the day. Patients can also choose a provider from a list of who is available. It is all handled by the software, so we can ensure there is a smooth opportunity for patients to be seen without a long wait. The average wait for a virtual urgent care visit is about 10 minutes."
The fee for a D-HH Virtual Urgent Care visit is $49 for D-HH employees and dependents who are on the health system's insurance plan and $59 for other patients. "We based our fee on the lower end of the market price. We have a slightly lower rate for our employees who are on our health plan, and we didn't want there to be too much of a difference between the fee for our employees and the fee for other patients," she says.
At this point, the fees are self-pay, Lowry says. "We are working toward being able to accept and process insurance payments; but for now, we are leaving it up to patients to identify with their own health insurance plans whether the virtual urgent care visit is covered. Patients can use a debit card, credit card, and healthcare spending account card."
For patients with D-HH primary care providers, virtual urgent care visit notes are shared electronically with the PCPs. For other patients, visit notes can be shared with PCPs via e-fax.
Virtual urgent care best practices
There are several best practices for providing virtual urgent care visits, Ebert says.
Technology plays a significant role, he says. "If it is a video visit, having high-quality visualization of the patient is very important. Audio is also a factor—being able to clearly hear the patient is very important."
Clinicians should conduct virtual urgent care visits in a space that is quiet, free of distractions, and capable of maintaining patient confidentiality, Ebert says.
Physician engagement with the patient is essential, he says. "Even though you are not able to physically reach out and touch the patient, the engagement process and establishing rapport with the patient in an environment of trust and empathy is very important. That comes mainly through eye contact and tone of voice, which allows the clinician to gain a better capability to get a comprehensive history from the patient and ultimately leads to a diagnosis."
Open and honest communication builds trust, Ebert says.
"The clinician needs to be direct with the patient and to be honest about impressions of the case. With a health complaint, the clinician should create a differential of what the possibilities are. You need to be open. You need to clearly voice what you believe to be going on or what you do not know to be going on. Then you need to guide the patient to the appropriate resources if the case is beyond the scope of what you can do through telehealth."
WMCHealth shares the keys to success in the Hudson Valley's effort to vaccinate people as quickly as possible.
In New York State, health systems have played a pivotal role in coordinating the distribution and administration of coronavirus vaccines.
The coronavirus vaccination effort is one of the most ambitious public health campaigns in U.S. history. A primary goal of the effort is to achieve herd immunity, which would make the spread of coronavirus unlikely. Anthony Fauci, MD, President Biden's chief medical advisor, has said 70% to 85% of the U.S. population needs to be vaccinated to achieve herd immunity.
New York State designed its vaccination efforts by dividing the state into 10 regions, and each of the regions was assigned a vaccination hub. For example, in the seven-county Hudson Valley region, Westchester Medical Center Health Network (WMCHealth) is the administrator of the vaccination hub. In Long Island, Northwell Health is the administrator of the vaccination hub. In the Albany region, the hub administrator is Albany Medical Center.
The vaccination hubs are key players, says Josh Ratner, MPA, executive vice president and chief strategy officer at Valhalla, New York-based WMCHealth.
"Each hub was asked to put together a vaccination plan on how we would approach vaccine distribution and equity in our regions. After that plan was submitted, our primary purpose was to be the command and control as well as logistics coordinator for our regions. That includes a wide range of responsibilities except for making vaccine allocations—who gets how much vaccine is determined by the state," he says.
The Hudson Valley vaccination hub recently passed the 1.3 million mark for vaccine dose coordination, Ratner says. Vaccine dose coordination, which applies to first and second doses, includes the following activities:
If there is a provider who has too much vaccine and a provider who does not have enough vaccine, the vaccination hub redistributes the vaccine
Ensuring that nursing home staff and residents receive enough vaccines
Fielding hundreds of calls from providers who have had questions about eligibility criteria, documentation requirements, and scheduling based on New York State guidelines
Targeting Zip codes that fall below state averages for first-dose vaccinations—the vaccination hub can coordinate with provider partners to establish pop-up vaccination sites in particular Zip codes
Weekly and bi-weekly meetings with country health departments and county executives
When providers want to transport vaccine from one location to another, those requests are routed through the vaccination hub for approval
"At WMCHealth and the Hudson Valley hub, we monitor vaccine administration, and we ensure that there is regional planning, including redistribution of vaccine. That means we effectively make sure that no dose gets wasted and as many shots in arms happen as quickly as possible," Ratner says.
Promoting collaboration and health equity
WMCHealth has led the effort to form several groups to support the distribution of vaccine in the Hudson Valley region, including a provider workgroup, regional task force, and health equity task force.
The provider workgroup includes any organization that has been approved by the state Department of Health to be a vaccinator, whether they have received vaccine or not, Ratner says. "Up until recently, there were about 330 eligible locations where someone could be vaccinated. Whether they are a pharmacy, or a hospital, or a physician practice—we have a weekly meeting with representatives from those locations to touch base on what is going on. We collaborate with every provider who wants to be collaborated with."
The regional task force has more than 450 members, he says. "The regional task force was originally comprised of suggested groups such as community organizations, municipalities, social service organizations, and providers. Up until recently, the regional task force has met weekly to review data, get on-the-ground feedback, and discuss challenges and opportunities."
The health equity task force features more than 70 clinical experts and community stakeholders, including leaders of faith-based organizations and social service agencies. "The health equity task force is essential to ensure that we have fair and equitable distribution of vaccine across our region. The health equity task force makes sure that we are looking at health literacy, access issues, and vaccine hesitancy," Ratner says.
Effective communication has been essential in the collaboration efforts, he says. "The key to our success has been frequent and fully transparent communication with our region's providers. Over the past five months, we have been able to bring together groups that previously were not collaborating—certainly not on a weekly basis."
WMCHealth playing dual role
In addition to playing a leadership role in the Hudson Valley vaccination hub, WMCHealth is also administering vaccines.
"We are involved in the actual administration of the vaccine for our network, which has 10 hospitals in the Hudson Valley. So, we are not only responsible for the hub but also are a provider. We provide vaccine at each of our hospital locations. In addition, WMCHealth is the state's provider partner for all four of the state mass vaccination sites in the Hudson Valley. Our providers staff those sites," Ratner says.
So far, about 55% of the vaccine-eligible population in the Hudson Valley has received at least one dose, he says.
